close

Вход

Забыли?

вход по аккаунту

?

2267988

код для вставки
58
THE BRITISH JOURNAL O F SURGERY
MULTIPLE POLYP1 OF THE COLON.
BY SIR W. I.
DE
C. WHEELER, DUBLIN.
POLYPOSIS
OF the intestinal tract is not b y any means a.s rare as was formerly
supposed. The relative frequency of polypi in the rectum is probably more
imaginary than real, for the ease of diagnosis in this situation is in sharp
contrast to the difficulties encountered when other portions of the alimentary
canal are invaded. Difficulties, both in diagnosis and treatment, were encountered in two recent cases of polyposis of the colon which have stimulated the
desire to place them on record and t o review some of the literature. I n the
first case the condition was not recognized either before or during the course
of two operations, and yet the findings were so definite that, if a second similar
case mere encountered, recognition during operation in all probability would
present little or no difficulty.
CASE REPORTS.
Case 1.-Polyposis
with Symptoms of Ulcerative Colitis.-In May,
1924, a girl, age 26, was admitted t o Mercer's Hospital, with a history
of constipation, followed after the use of laxatives by loose bloodstained
motions which had persisted for two years. Stated briefly the symptoms
were those of ulcerative colitis. Palpation revealed tenderness over the
right segment of the colon, and a n elongated tumour could readily be felt.
The temperature ranged from 99" t o 102", running normal for two or three
days a t a time. Loss of weight, ansemia, pyrcxia, and the presence of a
tumour led t o the clinical diagnosis of a malignant or tuberculous tumour of
the cxcum. The possibility of actinomycosis, colospasm, or a specific lesion
was considered. No definite information was forthcoming from X-ray examination ; the report stated t h a t twcnty-four hours after the barium meal
the bowels had moved several times, and very little barium remained in the
colon. Some was in the transverse and some was in the pelvic colon, but the
relationship of the tuniour t o the bowel was not defined ".
FIRSTOPEEATION.-After some preliminary treatment with arsenic a i d
by blood transfusions the abdomen was opened.
The colon presented a quite unfamiliar appearance. From just above
the ciecum (which was normal) t o the junction of the descending with the
pelvic colon7 the walls wcre hyperaemic, and infiltrated t o such an extent as
to convey the impression t h a t any rough handling or angulation would break
it in two. There wcrc no adhesions. The ileum and pelvic colon were shortcircuited, an appendicostoniy was established, and, after removal of a small
])ortion of the bowel wall for examination, the abdomen was closed.
The late Professor O'Sullivan reported that the specimen showed no signs
of malignancy, but septic inflammation of the mucous meinbralie was present.
LL
MULTIPLE POLYP1 OF THE COLON
FIG.39.--Polyposis of tho colon. Drnwing inado Iinmedintely nfter reniovnl.
Thc c m m i and luwer portion of the pelvic colon wore free from polypi. Tlw
spcciineli weigliecl 2 i Ib.
59
60
THE BRITISH JOURNAL O F SURGERY
After three weeks' irrigation through the appendicostomy the patient
was discharged from hospital to the country, and told t o report again in six
months.
On re-admission a t the end of this period the tumour 011 the right side
coitld still be fclt. The S - r a y report was as follows :-After six hours the czcum was incompletely filled and found very irregular
in outline. The bowels had moved several times, and only traces of barium werc
present in the ascending, transverse, and descending colon. A large, oval-shaped,
barium-filled sac was shown lying obliquely in the pelvis, and more to the right than
the left side.
As this barium-filled sac was not present a t the first X-ray examination,
i t was assumed that the barium collected a t the line of the previous ileocolic
anastomosis. For five months pain and diarrhea had continued, but the
hiemorrhage which had been present before operation had now ceased.
SECOND OPERATION.-T~~
abdomen was again
opened. Neither the appearance nor the feel of
the colon had changed ; there was the same rigidity
of the walls from a level above the ciecuni to the
pelvic colon ; these two postions were normal, and
in striking contrast t o the remainder of the bowel.
A long tube was passed up the rectum and guided
through the anastomosis betwe&i the ileum and
pelvic colon. The colon was removed from the
ileoczecal junctioii t o the line of anastomosis. The
specimen weighed 24 lb. (The weight of the average
normal colon is approximately 1 lb.) When opcned,
myriads of polypi were found studded over the
mucous membrane without interval from a line just
above the caxiim t o the lower portion of the pelvic
colon (Fig. 39).
On the third day after operation the patient
became distended, the tube passed through the
ileocolic anastomosis did not drain, and ominous
black vomiting supervened. Lavage of the stomach
and efforts to establish drainage were unsuccessful,
and the patient died. An autopsy was refused.
The polypi on section were of the adenomatous type.
Case 2.4nfantilism due to Polyposis of the
Colon.-The
second case was seen in March, 1925.
The patient was a girl, 16 years of age, stunted
40.--1nfanti1ismin
and dwarf-like, but not emaciated. Since early
a girl, age 16, with polyposis
childhood she had suffered from diarrhaa and the
of the colon.
passage of blood in the stools. Her height on
admission to hospital was 4 ft. 5 in. and her weight 4 stone 13 lb. (The
average normal height a t this age is 5 f t . 1 in., weight '7 stone 8% lb.)
The breasts were undeveloped, and there was an absence of asillary and pubic
hair (Fig. 40). Mentally she was alert and normal.
MULTIPLE POLYP1 OF THE COLON
61
Tn the course OF roiitiiie esamiiintion tlie differential blood-count was
iiotcwortliy owing to tlie great iiic~easeof the eosinophils, which raised ill
the iiiiiid of tlic pathologist a suspicion of the presence of intcstiaal parasites.
'l'lie wliite blood-cclls were as follo~w: polyniorplis 22, Iylnpliocytes 59,
large i ~ i o ~ i o ~ ~ ~ icells
c l c a5r, eosinophils 14 ; poikilocytosis marked ; 110 iiiicleatecI
rcd cells.
Tiifantilisin has bceii clefiiial as " ail aiionialy of dedopnieiit cliaracterizecl
by the pcrsisteiice of the iiioqhologhrl clmactcrs of childhood in an iuclividual
wlio hits rcachetl or passed the age of piibeity " (Zuiidel). It is iiot surprising
to liiid iiifnntilisni nssocititcd with polyposis of
tlic c*oloii.but so f w as cnii be ascertained t.liis
is tlic OIII>~ case 011 record.
Apart from the so-called idiopathic in fantilisni, a i i t l the infantilism diie to general
clisvirscs siirli as syphilis s i r c l tuberonlosis, a i d
t l i ~ form
t
associated with the iiit.eriiii1secretion
ol' itl)iiorinnl glaiicls, cliroiiic tlitirrlima fro111
vtirioiis causes appears to be responsible for tlie
coiitlitioii in the majority of cascs.
Ryroni Brainwell1 calls atteiitiou t o infantilisiii of paiicreatic origin in which diarrhwa
is tlic proiiiiiieiit syiiiptom, and i t is interesting t.o nett that such cases :ire cured by the
;uliiiiiiist ration of pancreatic estract.
hIoorIieac1~reviews t.lic literature and disciisses rases of infttiitilism -panci~atic and
intestii~al. After a very complete description
of a post-niorteni on a girl of IS, tliis latter
writer states : " To siiiii 111). the ap1)areiitlp
priin;iry ~~ttliological
cliiilige in this rase w t s
ctrtitrr~l
of tile co~ollalld l)robabiy
or tile
siiiall intestine, aiid iii consequelice one inay
regard t.lie case 8 s one of iuidoubtecl iiitcstiiial
iiifaiitilisiii
In the case under rcview the polypi in\-:~Icdthe rrctiini and c o d d easily be prolnpsed,
I)iit- it wiis only dnriiig the course of two
operations t.liat tliey wcrc found to estciid
of
4
~
~
up~vards tliroiigli tlie desceiidiiig coloii and
s~uddedover wit11 polypi.
traiisvcrse colon, and probably into the aseelidiiig aiid crucal seginciit. Proctoscopic esariiiiiatioii in this, a s in the first
case iiieiit.ioned, was unsatisfactory ; it was impossible, after passing through
a 1 1 area of polypoid iiiiicoiis nictiihriiiie, to obt,aiii 11 rleilr visual iield owing
to tiIe llrcsellce or Illis, lllllclls, alld bioori.
Finsr Oimfa.riox.-~Iarch 3, 1035. The sphincter tvns diltited. The
iiiiicous menibrane of the rectum was casily estruded, and was foulid covered
wit11 sinall polypi. Tlic iiiiicoiis iiieiiibraiie was raised froin the subiiiucous
coat by injections of iiorocain and adrenalin, and a wide cuff \vas removed,
".
7;
;
62
THE BRITISH JOURNAL O F SURGERY
isolated polypi were cauterized, aiid the dividccl niticous membrane was
sutured end t o end.
The interior of the bowel could be reached to a high level ; but a t the
conclusion of the operation polypi could be felt still higher u-ith the tip of
the finger.
SECONDO P E R - ~ T I O X . - ~ l l l ~ 30,
~
1925. The pelvic colon was exposed
through a left parmiediaii invision. A loop was opened for exploration,
and the mucous nieiiibraiie mas found covered with polypi. The loop mas
niobilized, and the limbs were sutured in parallel fashiou and fixed to the
abdominal wall by tlie mcthotl of Rlikulicz. The estruded portion, measuring
S $ in., was removed after n few days with the cautery. Numerous polypi
FIG.42.-Polypi
cstriidcd through the culostotny after partial colectoiny.
were found on opening the portion renioved, but thcy were not diffuse, and
the infiltration and loss of flexibility found in the first cnsc were in consequence absent (Fig. 41). A fiiigcr passed into the lower liiiib could detect 110
trace of further growths ; but 011 esaniiriillg the upper limb pedunculatecl
polypi could be felt as high as the splenic flexure.
I n a few days numerous polypi appeared through the upper limb of the
colostomy wound, and were removed with the cautery. A week later, further
polypi were cstrucled and removed in the same way (Fig. 42). After an
interval of some weeks capillaries containing radium emanation were inserted
in the end of a rubber tube and passed through the colostomy t o as high a
level as possible. The tube was removed little by little so that the emanation
would be brought into contact with a wide area of mucous coat. Finally, all
MULTIPLE POLY PI O F THE COLON
63
trace of blood disappeared, and the colostomy was closed by crushing the
spur and the introduction of a few sutures.
In January, 1926, the mother reported that the child was progressing
well ; she had put on nearly a stone weight and had grown one inch in
ten months. Bleeding and diarrhea had ceased.
In March, one pear after the commencement of treatment, the bloodcount approached normal. Eosinophils had fallen to 1 per cent, polymorphs
had risen t o 75 per cent, large mononuclears 15 per cent, lymphocytes 9 per
cent. Pubic and axillary hair had appeared, and there were further signs of
general development.
PATHOLOGICAL
REPORT.--A~~
polypi appear in section as simple adenopapillomata. No sign of malignancy.
DISCUSSION.
Proctoscopic and X-ray examinations in the two cases under review were
of little avail in making a diagnosis. In the first case the rectum and lower
portion of the pelvic colon were unaffected, and above this level the field was
obscured by fluid faxes, mucus, and blood. X rays confirmed the clinical
picture of ulcerative colitis, and later showed the ileocolostomy, but did not
go further. In the second case multiple polypi were present in the rectum.
Kiimbers of them attached to a prolapsed mucosa could be protruded through
the anus. The field of vision in this case was also obscured when the proctoscope was further introduced along the polypi-bearing mucosa. Barium given
through the colostomy opening was not retained sufficiently to give a satisfactory X-ray picture. Reliance is, however, placed on these two methods
of examination by Struthers and other authorities. Struthers3 opens a most
illuminating paper by alluding to Rontgen-ray examinations and the diagnosis
of multiple polypi before operation or death.
All authorities are agreed as to the association between ulcerative colitis
and polyposis, and in this connection the possibility of chronic ulcerative
colitis in children should be borne in mind. In the second case the symptoms
of colitis appear to have commenced a t about the age of 10.
helm hot^,^ in recording five cases, the average being under 10 years, says
he has failed to find a single article on the subject of this condition of ulcerative colitis in childhood. He thinks it was the terminal stage of ulcerative
colitis of adults which was described by Rokitansky, Virchow, and others
as polypi of the colon. According to some authorities the origin is congenital,
and others lay stress on the familial type.
Pennant,5 commenting on the first case I have mentioned in this paper,
describes the post-mortem on a case of polyposis of the colon. The patient's
brother was admitted six months later to hospital with a malignant growth
in the left iliac fossa. A colostomy was performed, and the colon was found
loaded with polypi similar to those found in the colon of his brother. A third
brother came to visit him in hospital, and complained of the frequent passage
of blood in the stools. The mother died of cancer a t an early age, and a sister
of carcinoma of the uterus a t the age of 24.
There are many references in the literature to intestinal polyposis.
Hewitt and Howard,6 of Cleveland, refer to cases published as far back
64
THE BRITISH JOURNAL O F SURGERY
as 1721, 1532, 1839, and 1861, and two more kecent cases recorded in 1905
and 1913. The formation of polypi following chronic ulcerative colitis is
emphasized. The following cases are mentioned as illustrative of many
interesting points :A woman, age 36, under the personal observation of Hewitt and Howard, in
about the year 1905, had been afflicted for a considerable time with severe diarrhoea,
and died in hospital a few weeks after admission. A t the post-mortem examination
the only lesion of importance found was in the colon. Here the entire mucous
membrane, from the ileocaxal valve to the rectum, was uniformly deeply ulcerated,
with ragged tags of mucosa scattered widely.
-4 second case, a man, age 40, was admitted to the Cleveland City Hospital in
1913. Diarrhoea was again the outstanding feature ; the temperature was variable,
hut never above lolo. The patient died in hospital. At post-mortem examination,
the mucosa of the lower two-thirds of the ileum was injected, edematous, and its
surface covered with a thin, greyish layer of exudate. In the lower portion of the
ileum, near t h e ileocecal valve, and in the cecum, there were single ulcers, which
are minutely described. On the base of several of the largest ulcers there were
attached islands and tags of miicosa and submucosa. The wall of the mucosa was
thickened, rather fibrous, and stifflyflexible. In the ascending and transverse colons
there were many small tufts of mucosa attached by slender pedicles easily detached
by passing the finger over the surface. Just above the sigmoid flexure there were
a few small polypoid projections ; they were stubby and attached by a relatively
thick pedicle ; and, above this again, there was a cluster of large and long polypoid
masses. The sigmoid flexure itself was the site of many projections, becoming more
numerous as they extended downwards t o the external sphincter, but in all there
were not more than forty such projections.
Hen-itt and Howard thought, from a study of these two cases, that the
islands and tags of mucosa and submucosa had been the source of the polypi,
which appeared t o depend for their preservation 011 the blood-vascular
arrangement, for i t was noted that the polyps in the rectum were situated
along the side of the intestinal wall, while higher up and in the colon the
polyps were situated along the line of attachment of the mesentery, an arrangement that coincides with the blood-supply of the parts.
It is assumed that the beginning of the disease is a general ulcerative
colitis. The ulcerative process is of such a character that portions of the
mucosa and submucosa adjacent t o the primary arterial branches are preserved,
and these portions remain as ragged tags scattered over the surface af the
colon. As the ulcers heal, these tags become smoothed off, and remain as
rounded sessile elevations, or as polypoid projections of the mucous surface.
Later on, as cicatrization proceeds, the orifices of certain of the tubules
situated in and between the polyps may become occluded, and retention cysts
form, giving rise t,o what Virchow called ‘colitis polyposa cystica’. It is the
end-stage of colitis polyposa. By some authorities a subtle distinction is
made between adenomata, papillomata, and true polypi ; but i t appears
likely that one is but a stage in the development of the other.
In the Proceedings of the Boyd Society of Medicine, 1914, cases are
recorded by Ivor Back, Gordon Watson, Norbury, and Furnivall.
Back’s patient was a girl, age 24. The condition was diagnosed, microscopically and clinically, as carcinoma of the rectum. A colotomy was
performed, and adenomata were found extending u p into the transverse
colon, and they subsequently bulged through a colotomy opening. About a
MULTIPLE POLYP1 OF THE COLON
65
year later she put on weight rapidly, and the polypoid excrescences had
disappeared from the rectum and from the region of the colotomy wound.
In Gordon Watson's case there were numerous edematous polypi
throughout the large intestine, with carcinomatous change in the sigmoid
flexure. After resection of the sigmoid the patient ultimately died of hemorrhage, and secondary growths were found in the lumbar glands and the liver.
Norbury's case was one of multiple polypi of the rectum and colon, with
prolapse of the bowel. The rectum and pelvic colon were studded with small
sessile polypi which were afterwards found to extend as high as the descending colon. Fixation of the bowel to correct the prolapse, with appendicostomy, was the operation performed.
In a discussion which followed, Lockhart-Mummery said that he believed
that the only satisfactory treatment for these cases was complete excision
of the entire colon after an ileorectostomy.
The late J. B. Murphy7 recorded a case of polyposis of the sigmoid, and
says that the etiology of intestinal polypi, like that of the common wart, is
shrouded in mystery. Whence they come, how they go, is like the riddle of
the Sphinx. Quoting Carroll, of the Mayo Clinic, he says that intestinal
polyposis is a comparatively rare disease. Polypoid growths may occur at
any point along the gastro-intestinal tract; but in the majority of cases
they are found in the large intestine, usually a t its turning points, and in the
rectum. A diagnosis can be made only when the polypi are seen or felt.
In Murphy's case the microscope showed adenoma with suspicious areas
of active cellular proliferations.
Lockhart-Mummerys describes a case of complete resection of the large
bowel for multiple adenomata. Numerous adenomata were found in the
rectum and sigmoid which extended as high up as the czcum and all through
the transverse colon. The specimen showed multiple adenomata of a simple
character throughout the entire large intestine.
Struthersg illustrates two specimens which appear almost identical with
the specimen illustrated in Fig. 39, but in boih his cases an adenocarcinoma
was found in the rectum. He gives an excellent reviewlo on what he calls
" multiple polyposis of the gastro-intestinal tract ".
Eighty-four cases in all
are considered, two of which showed multiple polypi in the small intestine,
an extremely rare condition. The various portions of the gastro-intestinal
tract involved, according to this writer, are as follows : stomach, 4 cases ;
czcurn to the rectum, 3 ; rectum and sigmoid, 2 ; hepatic flexure and small
intestines, 1 ; small intestines, 1 ; transverse colon, splenic flexure, and
descending colon, 1 ; descending colon and sigmoid, 1.
Copell publishes one case of multiple papillomata of the small intestine
causing recurrent intussusception in an adult ; and Mills12 reports a case of
multiple polypi of the stomach, a condition which is generally regarded as of
great rarity.
The question of ultimate malignancy is discussed, and Lockhart-Mummery
is quoted as having said that almost all recorded cases of multiple polypi of
the colon eventually became malignant, and that this was the factor to be
reckoned with in treating these cases.
Erdmann and Morris13 state that the disease has a marked prcdilection
VOL. XIV.-NO.
53.
5
66
THE BRITISH JOURNAL O F SURGERY
for the male sex, but this statement is not borne out by a reference to the
published cases. Attention is called by these writers to tlie fact that the
adenomatous type of polypi is most frequent in the large intestine, usually
in a multiple and widely disseminated form. The malignancy incidence they
state is 43 per cent (Soper).
Soper14 calls attention to the fact that L L comparatively few cases of
multiple polyposis of the colon are reported in literature
He analyses the
grand total of 61 cases, and calls attention to the tendency for the growths
to occur in the same family. A case is described (the second on record) in
which the entire colon was successfully resected for polyposis.
In view of the distribution of the polypi in C d e 1, it is interesting to
note that, according to Soper, the rectum and sigmoid are involved in 95 per
cent of all cases of polyposis of the colon. He thinks that sigmoidoscopic
examination is the only means by which an accurate diagnosis can be made.
T. S. Swan15 resected a portion of the transverse colon by the Mikulicz
method for the removal of a papillary adenoma. The diagnosis was made
by exploration. Diarrhea with the passage of blood was the outstanding
symptom.
".
CONCLUSIONS.
1. There is a close association between ulcerative colitis and polyposis.
Ulcerative colitis occurs in children as well as in adults,
8. The majority of cases sooner or later become malignant.
3. A condition of infantilism may result from polyposis of the colon in
early life.
4. Polyposis of the colon cannot be diagnosed unless the polypi are seen
or felt. Satisfactory X-ray and proctoscopic examinations are only possible
in a proportion of cases.
5. When multiple polypi of a very diffuse nature are present in the colon
there is a characteristic infiltration and want of flexibility in the walls which
is unlike any other pathological condition. When handling the colon the
increase in weight is very striking.
6. The prognosis is bad unless colectomy is performed. Ileostomy,
czcostomy, or appendicostomy, followed by irrigation, has been successful
in a few cases.
REFERENCES.
Edin. Med. Jour., 1015, May.
BRAMWELL,
BYROM,
z
M
~ T. G.,
~ Dublin
~ Jour.
~
Med.
~
Sci.,
~ 1920,
~ Jan.
,
~ S T R U T ~ EMayo
R S , Cfinics, 1923.
HELMHOLZ,
Ibid.
PENNANT,
D. H., Bn'f, Med. Jour., 1025, i, 856.
HEWITTand HOWARD,
Arch. of IntmtaZ Med., 1915.
' MURPHY, J. B., Clinics, 1916, June.
8 L o ~ ~ ~ ~ J. ~P., ~PTOC.
- Roy.
M uSOP.
~ Med.,
~ ~1819.
~ ~ ,
a STRUTHERS,
Ann. 01Surg., 1920, Dec.
STRUTHERS,
surg. Gynecol. and Obst., 1924, May.
l1 COPE, V. ZACHARY,Brit. Jour. Surg., 1922, ix, 558.
l 2 MILLS, G . PERCIVAL,
Brit. Jour. Surg., 1922, x, 226.
l3 ERDMANN
and MORRIS, Surg. Gynecol. and Obsl., 1925,.April, 460.
SOPEU,Amer. Jour. Med. Sci., 1916, March, 405.
SWAIN,
T. S., Radiology, 1925,Jan., 55.
Документ
Категория
Без категории
Просмотров
2
Размер файла
658 Кб
Теги
1/--страниц
Пожаловаться на содержимое документа